Cholera is something else, it is the invisible, it is the curse of the olden days, of times passed, a sort of evil spirit that comes back and that surprises us so much that it haunts us, because it belongs to what appears to be a forgotten age. Doctors make me laugh with their microbe.

Guy de Maupassant1

John Snow memorial

Broadwick Street
(formerly Broad Street) showing the John Snow memorial and public house

Cholera is known nowadays as a relatively straightforward, treatable disease that infects the small intestine and is caused by the bacterium Vibrio cholera. The bacterium, which has the unique ability to survive the hostile conditions of the human stomach, is normally found in contaminated water or food and spread by ingestion of either. In severe epidemics it is transmitted almost exclusively by a population’s contaminated water source.2

Despite the scientific progress made in identifying and treating cholera, there remains a tendency to consider the disease as a product of societal or political structures. For example, in Zimbabwe, the turmoil over the last decade has decimated the once robust healthcare infrastructure and enabled the reemergence of the disease. When an epidemic struck in August 2008, 3 it was clear that the salient causes were a lack of medical amenities and a decline in5 basic levels of sanitation and water infrastructure. Yet the epidemic also became political when President Robert Mugabe refuted its very existence by attributing cholera mortality to a conspiracy: claiming the first world used the disease to channel aid to Zimbabwe and seize territory during a time of crisis.4 Even the World Health Organization (WHO) refers to cholera as a disease that only strikes areas that “lack social development,”5 risking to pigeonhole countries affected by cholera as primitive societies. In order to explain this social construction of cholera in our modern day, this essay argues that the current social understanding of cholera is entrenched in an historical precedent for interpreting the disease in an era that lacked a solid biological basis and fell back on social justifications for its etiology.

Cholera first appeared as a true issue of public health in the Ganges delta in India in June 1817.6 Over the next few years, the disease rapidly spread to most Asian countries and many parts of the Middle East, turning the outbreak into a pandemic. Following a brief respite, cholera re-emerged in full force in a second worldwide pandemic. Originating in Bengal in India in 1826, this second pandemic worked its way to Europe and eventually to the East Coast of the United States in 1832. The third pandemic began in 1840, striking England most severely in 1848–49. Anesthetist John Snow (1813–1858) proposed a bold new approach to the disease. In August 1849, he published a pamphlet on the biological underpinnings of cholera. While somewhat flawed, his theory was remarkably prescient and revolutionary given the state of biomedicine at the time.7 Snow claimed that cholera was an infection of the digestive tract caused by the unintentional ingestion of a “cholera poison” in human feces. This hypothesis allowed him to further postulate that the accidental consumption of the poison occurred due to the contamination of public water supplies.

Five years later, another epidemic struck London, giving Snow the opportunity to test his theory. The first of these investigations, at the Broad Street Pump in London, remains one of the most famous moments in the history of disease. When Snow became aware of the outbreak he began to keep a close eye on public waterworks. He noticed an anomaly with regard to the water pump at Broad Street: in 83% of the cases, the cholera victim had frequented the pump as their primary water supply.8 Although he could not empirically prove the pathogenic nature of the contaminated water, he made a speculation-based intervention by removing the handle of the pump so that it could no longer provide water. Although a correlated decline in cholera mortality shortly followed,9 he received very little attention for his findings from the English scientific community. For decades, until Robert Koch’s bacteriology work on cholera in 188410 and the establishment of germ theory by Louis Pasteur in 1902,11 the bacterial nature of cholera would continue to elude physicians and biomedical specialists throughout the world. Instead, biomedicine and greater society fell upon largely social explanations for the classification of the disease in order to compensate for a lack of true biomedical knowledge during this period. Nowhere was this social construction of cholera more pronounced than in the French capital of Paris.

In France during the 19th century, the emergence of the bourgeoisie12 created a great deal of social tension as these middle classes constantly endeavored to distinguish themselves from the poor. To do so, the bourgeoisie constructed a ‘moral code’ of conduct that reflected the antithesis of what it meant to live in poverty. In developing this moral code, French bourgeois civilization was heavily influenced by the Enlightenment and centered upon reason and scientific development.13 This led to the emergence of a set of middle class notions that represented a complex intertwining of morality and science, which hugely affected the 19th century medical discourse and the interpretation of health and disease.

For the Parisian bourgeoisie of the 19th century concepts of disease were rooted in a loose interpretation of morality and a capacity to conform to an ideal set of bourgeois conventions. An individual was deemed ‘moral’ or ‘immoral’ based on how well he could abide to the code of bourgeois conduct. This judgment of ‘morality’ became entangled with the perception of standards for health and hygiene, essentially “an abstraction … a set of recipes for healthy bourgeois living”14 and an erroneous, socially-driven perception of disease that was articulated in terms of class differences. All men suffering from this disease were seen as belonging to the working class, living in dirty, narrow streets,15 and having a propensity to engage in ‘immoral’ activity – such as holding a low class occupation or living in a crowded area.

Until the end of the 19th century, a common belief was that disease was caused by “miasma” – tiny particles in the air that resulted in foul odors and became associated with ill health and sickness.16 For the French bourgeoisie this provided a convenient linking mechanism between the social and biological effects of cholera. Miasmata were considered ‘infectious’ but not ‘contagious,’ meaning that the particles had a poisonous rather than a live pathogenic nature. This allowed for an environmentalist interpretation that high miasmatic concentrations could be attributed to poor living conditions possessing greater levels of “poisonous particles.” This notion is reflected in Eugène Sue’s archetypal bourgeois description of the neighborhoods occupied by the lower classes in his novel Les Mystères de Paris: “Dark streets, narrow and winding … dark and infected alleyways leading to even darker and even more infected staircases.”17 Through his word choice of “infected,” we detect Sue’s bourgeois voice instinctively conflating the muddled structures with disease. The disorganized and untidy streets, together with the amount of physical dirt, make the bourgeois author interpret the environment in terms of health, and by extension, morality. In an official government report that analyzed the 1832 Paris cholera epidemic, a health officer states:

The disproportion between the width of the streets and the heights of the buildings and the many narrow unaligned streets effectively make housing damp and unhealthy, depriving it of sunlight and air circulation. The influence of these factors becomes fatal if an epidemic or contagious disease develops in the capital.18

Here, the officer appears to conflate health and morality, viewing the twisted, narrow streets in Paris’s poor areas as indicative of disease and thus morally repugnant. Moreover, because these poorer living conditions were often accompanied by foul odors, miasmatic theory provided a scientific basis for associating disease with lower socioeconomic groups; by highlighting the putrid odor of the working classes, the bourgeoisie labeled them as disease ridden and infectious,19leaving explanations for causality rooted in a framework that inextricably associated social, urban, and economic factors with an erroneous biomedical understanding.

Unfortunately, the anachronistic social construction of cholera appears to persist in various ways. A 2010 study investigating the social and cultural features of cholera in Zanzibar revealed that many participants were unable to relate cholera to its precise etiology. Most participants described a generalized “dirty environment” as the primary cause of the disease and respondents living in rural areas were also more likely to refer to cholera in terms of witchcraft or “god’s will.”20 Although the biological basis of cholera is now known, such an understanding is far from universal, helping to explain why, even today, public health workers fail to control cholera epidemics, despite an intricate knowledge of the way cholera spreads and affects the human body.

In a recent article in the New England Journal of Medicine, Walden et al. argue that in modern public health terms cholera remains an affliction of society,,21 as much a symptom as it is a disease – a symptom of insufficient investment in assuring access to safe water and improved sanitation, reflecting the indisputable fact that the current state of development leaves more than a billion of the poorest and most marginalized people at risk of ingesting feces with their food and water.22 As a result, the eradication of the disease continues to elude the fields of biomedicine and public health. Given the misperceptions about the disease, a social interpretation of cholera becomes inevitable, highlighting the importance of disseminating accurate biomedical information so that a social construction of cholera is not misused and does not itself pose a barrier to access of safe drinking water and conditions of basic hygiene.

This paper will take the terms bourgeois, bourgeois class(es), middle class(es), and sometimes ‘bourgeoisie,’ to be virtually synonymous in reference to the all-encompassing group of individuals that held a socioeconomic position within society that placed them distinctly above the poor (or working) classes and below the aristocratic minority.

KHAMEER KISHORE KIDIA is from Harare, Zimbabwe, and graduated magna cum laude with a BA in French Literature from Princeton University in 2011. He was Rhodes Scholar at the University of Oxford where he received an MPhil in Medical Anthropology. His research there focused on sociocultural issues surrounding disclosure in HIV-positive adolescents in Zimbabwe. He is currently attending Icahn School of Medicine at Mount Sinai in New York where is a student in the Humanities and Medicine Program.